COVID Antigen Test – Patient Registration Form Cov-2 Patient Intake and Assessment Form First Name * Last Name * MI Email Address * Sex * Date of Birth * Race * Ethnicity * Patient Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode * Patient County of Residence Patient Phone Number Vehicle Description History of Present Illness Do you have any symptoms of COVID-19? Yes No If yes, when did the symptoms start? Have you had a known exposure to COVID-19? Yes No If so, when? By signing below, I consent to receive the CareStart COVID-19 Antigen Rapid POC Test. I also recognize that, pursuant to South Carolina Law §44-29-10 and Regulation §61-20, my results will be reported to the SC Department of Health and Environmental Services, whether positive or negative. Patient/Representative Signature Date For Pharmacy Use Only Specimen ID Test Collected Results Read Signature of Administering Pharmacist reCAPTCHA If you are human, leave this field blank. Submit Δ